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115th Congress    }                                  {       Report
                        HOUSE OF REPRESENTATIVES
 2d Session       }                                  {       115-1014

======================================================================



 
                      PEPFAR EXTENSION ACT OF 2018

                                _______
                                

November 9, 2018.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

    Mr. Royce of California, from the Committee on Foreign Affairs, 
                        submitted the following

                              R E P O R T

                             together with

                            ADDITIONAL VIEWS

                        [To accompany H.R. 6651]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Foreign Affairs, to whom was referred the 
bill (H.R. 6651) to extend certain authorities relating to 
United Sates efforts to combat HIV/AIDS, tuberculosis, and 
malaria globally, and for other purposes, having considered the 
same, report favorably thereon with an amendment and recommend 
that the bill as amended do pass.

                                CONTENTS

                                                                   Page
The Amendment....................................................     2
Summary and Purpose..............................................     2
Background and Need for the Legislation..........................     3
Hearings.........................................................    11
Committee Consideration..........................................    12
Committee Oversight Findings.....................................    13
New Budget Authority, Tax Expenditures, and Federal Mandates.....    13
Congressional Budget Office Cost Estimate........................    13
Directed Rule Making.............................................    14
Non-Duplication of Federal Programs..............................    14
Performance Goals and Objectives.................................    14
Congressional Accountability Act.................................    15
New Advisory Committees..........................................    15
Earmark Identification...........................................    15
Section-by-Section Analysis......................................    15
Changes in Existing Law Made by the Bill, as Reported............    15
Additional Views.................................................    37

                             The Amendment

    The amendment is as follows:
  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``PEPFAR Extension Act of 2018''.

SEC. 2. INSPECTORS GENERAL AND ANNUAL STUDY.

  Section 101 of the United States Leadership Against HIV/AIDS, 
Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7611) is amended--
          (1) in subsection (f)(1)--
                  (A) in subparagraph (A), by striking ``2018'' and 
                inserting ``2023''; and
                  (B) in subparagraph (C)(iv)--
                          (i) by striking ``four'' and inserting 
                        ``nine''; and
                          (ii) by striking ``2018'' and inserting 
                        ``2023''; and
          (2) in subsection (g)--
                  (A) in paragraph (1), by striking ``2019'' and 
                inserting ``2024''; and
                  (B) in paragraph (2)--
                          (i) in the heading, by striking ``2018'' and 
                        inserting ``2024''; and
                          (ii) by striking ``September 30, 2018'' and 
                        inserting ``September 30, 2024''.

SEC. 3. PARTICIPATION IN THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS, 
                    AND MALARIA.

  Section 202(d) of the United States Leadership Against HIV/AIDS, 
Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7622(d)) is amended--
          (1) in paragraph (4)--
                  (A) in subparagraph (A)--
                          (i) in clause (i), by striking ``fiscal years 
                        2009 through 2018'' and inserting ``fiscal 
                        years 2004 through 2023'';
                          (ii) in clause (ii), by striking ``2018'' and 
                        inserting ``2023''; and
                          (iii) by striking clause (vi); and
                  (B) in subparagraph (B)--
                          (i) by striking clause (ii);
                          (ii) by redesignating clauses (iii) and (iv) 
                        as clauses (ii) and (iii), respectively;
                          (iii) in clause (ii) (as redesignated by 
                        clause (ii) of this subparagraph)--
                                  (I) in the first sentence, by adding 
                                at the end before the period the 
                                following: ``or section 104B or 104C of 
                                such Act''; and
                                  (II) in the second sentence, by 
                                striking ``for HIV/AIDS assistance''; 
                                and
                          (iv) in clause (iii) (as redesignated by 
                        clause (ii) of this subparagraph), by striking 
                        ``2018'' and inserting ``2023''; and
          (2) in paragraph (5), by striking ``2018'' and inserting 
        ``2023''.

SEC. 4. ALLOCATION OF FUNDS.

  Section 403 of the United States Leadership Against HIV/AIDS, 
Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7673) is amended--
          (1) in subsection (b), by striking ``2018'' and inserting 
        ``2023''; and
          (2) in subsection (c), in the matter preceding paragraph (1), 
        by striking ``2018'' and inserting ``2023''.

                          Summary and Purpose

    H.R. 6651, the PEPFAR Extension Act of 2018, extends 
authorities, limitations, and reporting requirements relating 
to the President's Emergency Plan for AIDS Relief (PEPFAR), as 
initially authorized by Congress in 2003 and reauthorized in 
2008 and 2013, respectively. The bill extends through Fiscal 
Year 2023 a requirement for the Inspectors General of the U.S. 
Department of State, the Department for Health and Human 
Services (HHS), and the United States Agency for International 
Development (USAID) to develop joint auditing plans that ensure 
greater unity of efforts, reduce gaps in program oversight and 
performance, and eliminate waste. It extends through Fiscal 
Year 2023 annual reporting requirements relating to HIV/AIDS 
treatment providers and costs. It also extends two funding 
directives, including the requirement to allocate at least half 
of the PEPFAR budget to HIV/AIDS treatment and care, and at 
least 10 percent of the PEPFAR budget to children orphaned or 
made vulnerable by HIV/AIDS.
    The bill also addresses United States participation in the 
Global Fund to Fight AIDS, Tuberculosis, and Malaria (the 
Global Fund). Specifically, the bill extends the existing 33 
percent cap on U.S. contributions to the Global Fund and 
clarifies that the limitation applies to cumulative 
contributions made between Fiscal Years 2004 and 2023. It 
extends through Fiscal Year 2023 a requirement to withhold 
contributions to the Global Fund in an amount equal to any 
assistance provided to a State Sponsor of Terrorism and 
clarifies that any funds withheld from the Global Fund for any 
purpose may be made available for U.S. bilateral HIV/AIDS, 
tuberculosis, or malaria programs. The bill additionally 
extends through Fiscal Year 2023 a requirement to withhold 20 
percent of planned annual U.S. contributions to the Global Fund 
until statutory transparency requirements are met.

                Background and Need for the Legislation

    PEPFAR, the largest bilateral global health initiative 
aimed at combatting a single disease in history, was first 
announced by President George W. Bush during his January 28, 
2003, State of the Union Address. The closely held--but 
welcome--announcement took experts and advocates by surprise, 
including those leading efforts within USAID and the Centers 
for Disease Control and Prevention (CDC) to combat the HIV/AIDS 
pandemic, as well as Members of Congress, many of whom had been 
advocating for a more effective response for several years.
    ``Seldom has history offered a greater opportunity to do so 
much for so many . . . to meet a severe and urgent crisis 
abroad, tonight I propose an emergency plan for AIDS relief . . 
. a work of mercy beyond all current international efforts to 
help the people of Africa.''--President George W. Bush, January 
28, 2003.
    Congress promptly responded by enacting the ``U.S. Global 
Leadership Against AIDS, Tuberculosis and Malaria Act of 2003'' 
(P.L. 108-25, known as ``the Leadership Act''), which was 
signed by the President on May 27, 2003. The bill--supported by 
a diverse, bipartisan coalition of Members, advocates, 
academics, implementers, the faith community, non-governmental 
organizations, and other leaders from around the globe--
authorized a 5-year, $15 billion initiative to be led by a U.S. 
Global AIDS Coordinator within the Department of State. This 
initiative would concentrate resources in 15 ``focus'' 
countries to provide life-saving treatment for 2 million 
people, prevent 7 million new infections, and provide 
palliative care for 10 million people suffering from AIDS. The 
U.S. Global AIDS Coordinator was specifically charged with 
developing and overseeing implementation of a 5-year integrated 
strategy to meet these ambitious targets by aligning the 
efforts of relevant Federal departments and agencies 
(particularly USAID and the Departments of State, Defense, and 
HHS/CDC/NIH), managing resources, coordinating with other 
donors and partner countries, eliminating duplication and 
waste, and managing U.S. participation in the Global Fund. Of 
the funds made available for combatting HIV/AIDS globally, the 
bill required that 55 percent be directed toward treatment, 20 
percent toward prevention, 15 percent toward care, and 10 
percent toward supporting children orphaned or made vulnerable 
by HIV/AIDS.
    In addition to combatting HIV/AIDS, the bill amended the 
Foreign Assistance Act of 1961 (22 U.S.C. 2151 et seq.) to 
establish combatting malaria and tuberculosis as major U.S. 
foreign policy objectives and authorized ``such sums as may be 
necessary'' to carry out related programs. Finally, the bill 
authorized the United States to participate in the Global 
Fund--a multilateral financing mechanism established in 2002 to 
combat AIDS, tuberculosis, and malaria--subject to a 33 percent 
cap on U.S. contributions and other restrictions.
    At the time of enactment, fewer than 50,000 people living 
with HIV/AIDS in sub-Saharan Africa had access to life-saving 
antiretroviral treatment (ART). Health systems were collapsing 
under the strain of new infections and, with no treatment 
options available, patients were sent home to die. Teachers, 
factory workers, health care providers, and soldiers were dying 
faster than they could be replaced. Economies declined. In the 
hardest hit countries, life expectancy plummeted to just 30 
years. Newborns were infected by their mothers and, by 2003, an 
estimated 13 million children had lost one or both parents. The 
situation was so dire that, in January 2000, the National 
Intelligence Estimate identified the AIDS pandemic as a threat 
to U.S. national security, noting in particular that dramatic 
declines in life expectancy would heighten the risk of 
``revolutionary wars, ethnic wars, genocides and disruptive 
regime transitions'' in the developing world. The HIV/AIDS 
pandemic that was ravaging sub-Saharan Africa and parts of Asia 
and the Caribbean had evolved from a global health challenge to 
a national security threat.
    PEPFAR changed the course of the HIV/AIDS pandemic. During 
the ``emergency'' phase--Fiscal Years 2004 through 2008--
Congress provided over $18.8 billion for PEPFAR\1\, including 
over $3 billion in contributions to the Global Fund, enabling 
the program to rapidly scale-up testing, treatment, and care 
services in the 15 focus countries. An estimated 3.7 million 
health workers were trained, nearly 57 million people received 
voluntary testing and counseling (VTC) services, 2.1 million 
people received ART, and 10.1 million people, including 4 
million orphans and vulnerable children (OVC), were supported 
through care programs. In addition, prevention of mother-to-
child transmission (PMTCT) services were provided during nearly 
16 million pregnancies, helping to avert at least 240,000 
newborn infections.
---------------------------------------------------------------------------
    \1\PEPFAR totals include funding for bilateral HIV/AIDS programs, 
U.S. contributions to the Global Fund, and bilateral tuberculosis 
programs. Bilateral funding for malaria has been segregated since 
Fiscal Year 2006, after the launch of the President's Malaria 
Initiative (PMI). The cumulative total of funding for bilateral malaria 
programs under the PMI between Fiscal Years 2006 and 2017 is $5.65 
billion.
---------------------------------------------------------------------------
    Building upon the success of the Leadership Act, President 
Bush signed the Tom Lantos and Henry J. Hyde United States 
Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria 
Reauthorization Act of 2008 (P.L. 110-293, known as ``the 
Lantos-Hyde Act'') on July 30, 2008. The bill was intended to 
set the stage for a transition from an emergency program to a 
sustainable response that would build partner capacity and 
better enable focus countries to achieve epidemic control. To 
that end, it introduced the concept of country and regional 
``compacts'' or ``framework agreements'' that would more 
clearly define the commitments and responsibilities of the 
United States, the Global Fund, other donors, and the partner 
governments themselves in designing and implementing 
coordinated national HIV/AIDS strategies. It also established a 
requirement for the Inspectors General of the Department of 
State, HHS, and USAID to jointly develop annual oversight plans 
for the programs authorized under the Act.
    More broadly, the Lantos-Hyde Act reauthorized the PEFPAR 
program for an additional 5 years (Fiscal Years 2009 through 
2013), emphasized the importance of combatting malaria and 
tuberculosis, and increased HIV/AIDS prevention, care, and 
treatment targets. It increased the level of authorized 
appropriations from $15 billion to $48 billion, adjusted the 
funding directives for HIV/AIDS treatment and care to not less 
than 50 percent, and changed the OVC funding directive from a 
10 percent minimum requirement to a more permissive Sense of 
Congress. Finally, the bill reset the timeframe for calculating 
the 33 percent cap on U.S. contributions to the Global Fund 
from Fiscal Years 2004 through 2008 to Fiscal Years 2009 
through 2013 and added a requirement to withhold 20 percent of 
planned annual U.S. contributions until the Global Fund adopted 
certain transparency requirements.
    Over the second authorization period following the Lantos-
Hyde Act, Congress provided over $33.4 billion for PEPFAR, 
including nearly $6.4 billion in contributions to the Global 
Fund, enabling the program to significantly expand in size and 
scope. In Fiscal Year 2013 alone, PEPFAR provided VTC services 
for 57.7 million people, including 12.8 million pregnant women, 
nearly 800,000 of whom tested positive and received immediate 
access to ART in order to prevent mother-to-child transmission 
of the virus. Over 17 million people, including 5 million OVC, 
received palliative care and support, and 4.2 million men 
underwent voluntary medical male circumcisions.
    PEPFAR also continued to support a rigorous research agenda 
that contributed to the discovery of exciting breakthroughs in 
prevention and treatment. First-line antiretroviral therapies 
were improved, generics were developed, and supply chains were 
strengthened, all of which enabled PEPFAR to more than triple 
the number of people receiving life-saving treatment (from 2.1 
million people in 2009 to 6.7 million people in 2013). The 
expansion of treatment contributed to an overall reduction in 
HIV/AIDS morbidity and mortality rates and a subsequent decline 
in the number of HIV/AIDS orphans. Still, there were over 2.3 
million new infections in 2012--the year leading up to the 
PEPFAR Stewardship and Oversight Act--and appropriations had 
declined from a high of $6.87 billion in Fiscal Year 2010 to 
$6.58 billion in Fiscal Year 2013. The continuing and dire 
needs abroad and budget constraints in the U.S. would have to 
be reconciled.
    On December 2, 2013, President Obama signed the PEPFAR 
Stewardship and Oversight Act of 2013 (P.L. 113-56, known as 
``the Stewardship Act''). While the bill did not specifically 
authorize appropriations, it sought to enhance the transparency 
and accountability of PEPFAR and the Global Fund so continued 
appropriations could be used more efficiently and effectively. 
It required more rigorous analysis and public disclosure of 
prevention, treatment, and care needs in partner countries, as 
well as the costs supported by the United States, the Global 
Fund, and partner governments. The bill further conditioned 
U.S. contributions to the Global Fund upon enhanced 
transparency and improved grants management and pressed the 
Office of the Global AIDS Coordinator (OGAC) and the Global 
Fund to more clearly disaggregate and attribute results. It 
required comprehensive, annual studies on treatment costs and 
highlighted the need to establish metrics to measure partner 
country capacity to manage their own epidemics. It also 
extended through Fiscal Year 2018 the requirement for the 
Inspectors General for the Department of State, HHS, and USAID 
to jointly develop coordinated audit plans. Finally, it 
extended through Fiscal Year 2018 the funding directives for 
treatment and OVC and adjusted the 33 percent cap on U.S. 
contributions to the Global Fund to cover cumulative 
contributions between Fiscal Years 2009 through 2018.
    Over this period, following the enactment of the 
Stewardship Act, Congress provided nearly $34.19 billion for 
PEPFAR, including over $7 billion in contributions to the 
Global Fund. Thus, the U.S. has enacted a total of $79.7 
billion for PEPFAR since Fiscal Year 2004, including $14.7 
billion for the Global Fund.
    According to the latest available data, PEPFAR is 
supporting over 14 million people on ART and has provided VTC 
for over 85.5 million people, helped avert 2.2 million 
infections among babies born to HIV-positive mothers, provided 
over 15.2 million voluntary medical male circumcisions to help 
men and boys remain HIV-negative, and provided palliative care 
for 6.4 million OVC. Additionally, OGAC is pioneering new 
analytical tools, including Population-Based HIV Impact 
Assessments (PHIAs), which enable partners to gather data, 
identify needs, fill gaps, and measure results down to the 
site-level. By more strategically targeting resources and 
holding partners accountable for results, PEPFAR is helping 
reduce the number of new infections among the most vulnerable 
groups--particularly young women and adolescent girls between 
the ages of 15 and 24--by as much as 40 percent. These results 
are remarkable, yet more remains to be done.
    The PEPFAR Extension Act of 2018 has been informed by 15 
years of implementation and seeks to ensure that PEPFAR 
resources are used efficiently, effectively, and for the 
purposes specified by law so partner countries can achieve 
epidemic control. The bill supports efforts by OGAC and the 
Global Fund to expand access to treatment and prevent new 
infections; reasserts the 33 percent cap on U.S. contributions 
to the Global Fund while taking into account previous errors in 
calculating compliance; clarifies Congressional intent on how 
funds withheld from the Global Fund may be used; and continues 
support for OVC while directing implementers to adapt programs 
to better reflect current needs.
    Ensuring PEPFAR Resources are Used Efficiently, 
Effectively, and for the Purposes Specified by Law. A 
combination of budget realities, a change of leadership within 
OGAC, and the enactment of the Stewardship Act brought renewed 
emphasis to data and evidence-based programming within the 
PEPFAR program. Today, the Coordinator is using Country 
Operational Plans (COPs, influenced in part by the framework 
agreements envisioned in the Lantos-Hyde Act), the PHIAs, and 
other strategic planning tools to restore program discipline 
and ensure resources are being concentrated in the areas of 
greatest need. The committee notes that this shift has been met 
by episodic resistance in several partner countries and among 
implementers that take an expanded view of PEPFAR. The 
committee further notes that both PEPFAR and the Global Fund 
were established to combat three diseases: AIDS, tuberculosis, 
and malaria. While goals such as strengthening health systems, 
combatting non-communicable diseases, and establishing social 
safety nets for children in adversity are worthy objectives--
and PEPFAR and the Global Fund clearly have had corollary, net-
positive effects on these and other global health and 
development priorities--these objectives can and should be 
addressed through different initiatives. PEPFAR's past and 
future success is contingent on remaining focused upon the 
three core diseases.
    The committee supports the efforts of OGAC to align budgets 
with priorities, strategically target resources, and enhance 
coordination among Federal departments and agencies, the Global 
Fund, other donors, partner countries, and implementers, 
including through the annual COP process. The committee notes 
that the COP process is labor intensive and appreciates the 
efforts of participants to ensure that it serves as an 
effective planning tool that enhances transparency and 
accountability. The committee directs all participating Federal 
departments and agencies to strictly adhere to the COPs and to 
seek specific authority from OGAC if a deviation becomes 
necessary. Similarly, the committee directs all participating 
Federal departments and agencies to obtain explicit approval 
from OGAC prior to initiating research projects to be funded 
with PEPFAR resources. OGAC shall report patterns of 
noncompliance to the Committees on Foreign Affairs and 
Appropriations in the House and Foreign Relations and 
Appropriations in the Senate.
    The coordinated Inspectors General audit plans, studies on 
treatment providers and costs, and annual reporting 
requirements that are extended in this Act are critical to 
effective oversight and enhance the ability of OGAC to stretch 
resources farther, program for impact, and eliminate 
duplication and waste. The committee notes that execution of 
the coordinated audit plans has been inconsistent. The 
committee directs the Inspectors General to improve 
coordination and pursue a robust audits and investigations 
agenda, including by scrutinizing supply chains\2\ and OGAC's 
efforts to expand utilization of local partners to ensure 
resources continue to be used as efficiently and effectively as 
possible. The committee also recommends enhanced coordination 
with the Inspector General for the Peace Corps to ensure 
program integrity.
---------------------------------------------------------------------------
    \2\See ``Committee on Foreign Affairs Oversight Investigation: 
USAID Global Health Supply Chain Contract'', October 2018, available at 
https://foreignaffairs.house.gov/wp-content/uploads/2018/10/Oversight-
Investigation-USAID-Global-Health-Supply-Chain-Contract.pdf.
---------------------------------------------------------------------------
    Expanding Access to Treatment as a Form of Prevention. In 
2011, a study by the HIV Prevention Trials Network (HPTN), 
known as HPTN 052, began showing evidence that early initiation 
of ART could reduce the chances of transmission from an HIV-
positive person to an HIV-negative partner by more than 96 
percent.\3\ The Joint United Nations Program on HIV/AIDS 
(UNAIDS) seized upon these findings and, in 2014, launched 
ambitious ``90-90-90'' targets--whereby, by 2020, 90% of people 
living with HIV will know their status; 90% of those who know 
their status will be on treatment; and 90% of those accessing 
treatment will be virally suppressed. To reach these targets, 
the World Health Organization (WHO) recommended in 2015 that 
all countries move to a ``test-start-retain'' model--whereby 
all people diagnosed with HIV immediately start ART regardless 
of their CD-4 count (i.e., the measure of white blood cells, or 
T cells, in a patient's bloodstream) and strictly adhere to the 
treatment regime in order to achieve viral suppression. 
According to the WHO, universal adoption of ``test-start-
retain'' policies and related progress toward the 90-90-90 
targets would help avert 28 million new infections by 2030.
---------------------------------------------------------------------------
    \3\The results of the HPTN 052 study were finalized and published 
in the New England Journal of Medicine on September 1, 2016.
---------------------------------------------------------------------------
    On July 24, 2018, UNAIDS reported that considerable 
progress has been made--by the end of 2017, an estimated 75 
percent of people living with HIV knew their status, of which 
79 percent were receiving treatment, of which 81 percent were 
virally suppressed--but entire populations and regions in 
eastern Europe, central Asia, central and western Africa, and 
the Middle East and North Africa are still being left behind. 
Key populations, adolescents, and men are not being reached by 
traditional testing approaches, and adolescent girls in 
particular remain extremely vulnerable to infection. Moreover, 
gaps in political will, societal stigma and discrimination--
especially against key populations--and the imposition of user 
fees on HIV services remain significant barriers to progress.
    The committee is encouraged by progress in meeting the 90-
90-90 targets and encourages all partner countries to adopt 
effective test-start-retain policies and approaches. At the 
same time, the committee recognizes that flat budgets will make 
it increasingly difficult for OGAC and partner countries to 
expand access to treatment and prevent new infections.
    The committee expects OGAC to continue to collect, refine, 
and apply data so PEPFAR resources can be targeted to the areas 
of greatest need. The committee encourages OGAC, the Global 
Fund, and other partners to work with the private sector to 
develop and deploy cost-effective innovations in testing and 
treatment for hard-to-reach populations. The committee also 
urges partner countries to lower barriers to testing and 
treatment, including by eliminating user fees, strengthening 
supply chains, fighting stigma and discrimination, and enacting 
policies that allow for early adoption and transition to 
improved testing and treatment regimens.
    The Global Fund Cap. The Leadership Act of 2003 established 
a 33 percent cap on U.S. contributions to the Global Fund for 
each of the Fiscal Years 2004 through 2008, and the Lantos-Hyde 
Act of 2008 extended that cap for each of the Fiscal Years 2009 
through 2013. During negotiations over the Stewardship Act, the 
Administration indicated that they were having difficulty 
calculating the cap on a year-to-year basis because the Global 
Fund operates on a 3-year ``replenishment cycle'' and the 
fiscal years of other donors do not necessarily align with 
those of the United States. To that end, OGAC requested that 
they be allowed to apply the cap to cumulative contributions 
over the authorization period rather than annual contributions. 
Congress consented and extended the cap in the Stewardship Act 
so that it would apply to cumulative contributions between 
Fiscal Year 2009 through 2018.
    In late 2015, OGAC reported that they had misinterpreted 
how compliance with the cap was to be calculated. Rather than 
limiting U.S. contributions to the Global Fund to 33 percent of 
the cumulative contributions received between Fiscal Years 2009 
and 2018 as the Stewardship Act stipulated, OGAC had been 
applying the cap to cumulative contributions received between 
Fiscal Years 2004--rather than 2009--and 2018. Since total U.S. 
contributions to the Global Fund prior to 2008 were below 33 
percent, this calculation allowed OGAC to provide additional 
U.S. funding to the Global Fund. By the time the new Global 
AIDS Coordinator detected and reported the error in December 
2015, the United States had provided more than $500 million in 
excess contributions to the Global Fund. Without statutory 
relief, the consequence of this miscalculation meant that OGAC 
would have to pull back over $500 million from signed Global 
Fund agreements, potentially resulting in patients losing 
access to treatment.
    To avoid having to cut off treatment to patients in need, a 
bipartisan agreement to provide temporary cap relief was 
reached in December 2015 with enactment of the Consolidated 
Appropriations Act, 2016 (P.L. 114-113). This agreement, which 
simply substituted ``2004'' for ``2009'' for the purposes of 
calculating the Global Fund cap, was extended by the 
Consolidated Appropriations Act, 2017 (P.L. 115-31) and the 
Consolidated Appropriations Act, 2018 (P.L. 115-141).
    To ensure compliance with existing law and prevent the need 
to carry temporary relief through annual appropriations bills, 
the PEPFAR Extension Act of 2018 eliminates any ambiguity about 
how the cap is to be calculated during the next Global Fund 
replenishment cycle, by permanently amending the Leadership Act 
and applying the 33 percent cap to cumulative contributions 
between Fiscal Years 2004 and 2023. The bill also extends the 
requirement to withhold contributions to the Global Fund in an 
amount equal to any assistance provided to a State Sponsor of 
Terrorism and clarifies that any funds withheld from the Global 
Fund for any purpose may be made available for U.S. bilateral 
HIV/AIDS, tuberculosis, or malaria programs.
    Together, PEPFAR and the Global Fund have helped save 27 
million lives. The number of AIDS-related deaths has been cut 
in half since 2005, while malaria deaths have decreased by 60 
percent since 2000. In 2017 alone, over 79.1 million HIV tests 
were administered and 17.5 million people were receiving life-
saving ART. Nearly 200 million insecticide-treated bed nets 
were distributed, while 108 million people received treatment 
for malaria. Unfortunately, progress in combatting tuberculosis 
remains slow and hampered by significant gaps in case 
detection. Tuberculosis, while curable, kills more people 
worldwide than any other infectious disease and is the leading 
killer of people living with HIV/AIDS. As such, failure to 
accelerate progress against tuberculosis threatens to undermine 
the substantial progress achieved through PEPFAR and the Global 
Fund. Despite these challenges, an estimated 60 percent of 
tuberculosis patients know their HIV status and 85 percent of 
HIV-positive people co-infected with tuberculosis receive 
treatment for both.
    These results could not have been possible absent a laser 
focus on these three diseases. The committee urges the Global 
Fund to maintain this focus while exploring innovating testing, 
treatment, and financing options. The committee also reminds 
partners that U.S. participation in the Global Fund is 
voluntary. The committee directs OGAC to continue to condition 
U.S. contributions to the Global Fund upon performance and 
compliance with transparency and accountability requirements.
    Orphans and Vulnerable Children. In 2003, AIDS was a death 
sentence that was threatening a generation of caregivers in 
sub-Saharan Africa. According to UNAIDS and WHO, over 4 million 
children under the age of 15 had been infected--90 percent of 
whom had been infected by their mothers at birth or through 
breastfeeding--and another 13 million children had lost one or 
both parents to AIDS.\4\ In Zimbabwe alone, life expectancy had 
dropped to 37 years and 1.32 million children had become ``AIDS 
orphans.''\5\ Traditional communal care norms were broken and 
an alarming number of children were abandoned, left to raise 
other children, or forced to adopt negative coping mechanisms 
to survive. It was against this backdrop that Congress 
established the requirement under the Leadership Act to direct 
not less than 10 percent of the PEPFAR budget toward OVC.
---------------------------------------------------------------------------
    \4\The World Health Organization defines ``AIDS orphans'' as 
children under the age of 15 who have lost their mother or both parents 
to AIDS. See UNAIDS/WHO, ``2003 AIDS epidemic update: December 2003.'' 
https://www.who.int/ceh/risks/otherisks/en/index2.html.
    \5\See UNICEF, ``Africa's Orphaned and Vulnerable Generations: 
Children Affected by AIDS.''
---------------------------------------------------------------------------
    Thanks to PEPFAR's success, the scale and demographics of 
the OVC crisis have dramatically shifted. With treatment now 
much more accessible, parents and caregivers are surviving. The 
worst-case scenario predicted by UNAIDS in 2003--41 million 
AIDS orphans by 2010--has not come to pass.\6\ Moreover, the 
OVC of 2003 are now adults and require significantly different 
types of support than they did when the funding directive was 
established.
---------------------------------------------------------------------------
    \6\UNAIDS/WHO, ``2003 AIDS epidemic update: December 2003.''
---------------------------------------------------------------------------
    The committee believes it is important to maintain a focus 
on mitigating the harmful impact HIV/AIDS has on children and 
adolescents. However, the OVC programming supported by the 10 
percent funding directive extended by this Act must continue to 
evolve to meet the demands of a changing epidemic and its 
impacts on children and adolescents today. Despite having 
invested more than $2 billion in comprehensive OVC programs 
since Fiscal Year 2004, only 52 percent of children ages 0-14 
with HIV have access to ART and 180,000 children were newly 
infected in 2017. Effective OVC programming must take into 
account the aging population and, consequently, evolving needs 
of OVC, the disproportionately high risk of HIV infection and 
sexual violence for adolescent girls and young women, and the 
number of HIV-positive orphans yet to be diagnosed and linked 
to treatment. The committee directs OGAC to report on how 
PEPFAR--in particular the 10 percent OVC funding directive--is 
working to prevent new infections among OVC, with a particular 
emphasis on girls between the ages of 9 and 17, and to expand 
access to treatment for OVC.

                                Hearings

    Over the past 5 years, the committee has continued its 
active oversight of U.S. development, economic, and global 
health assistance programs, including 12 hearings related to 
the PEPFAR program:

          July 12, 2018, hearing before the Subcommittee on 
        Africa, Global Health, Global Human Rights, and 
        International Organizations on ``Combating Tuberculosis 
        in Southern Africa'' (The Honorable Deborah L. Birx, 
        M.D., U.S. Global AIDS Coordinator and U.S. Special 
        Representative for Global Health Diplomacy, U.S. 
        Department of State; Ms. Irene Koek, Deputy Assistant 
        Administrator, Bureau for Global Health, USAID; Rebecca 
        Martin, Ph.D., Director, Center for Global Health, U.S. 
        Centers for Disease Control and Prevention);
          May 17, 2018, hearing before the Subcommittee on 
        Africa, Global Health, Global Human Rights, and 
        International Organizations on ``Global Health Supply 
        Chain Management: Lessons Learned and Ways Forward'' 
        (Ms. Irene Koek, Deputy Assistant Administrator; Bureau 
        for Global Health, USAID; the Honorable Deborah L. 
        Birx, M.D., U.S. Global AIDS Coordinator and U.S. 
        Special Representative for Global Health Diplomacy, 
        U.S. Department of State);
          March 21, 2018, hearing before the full committee on 
        ``The FY 2019 Foreign Assistance Budget'' (The 
        Honorable Mark Green, Administrator, USAID);
          October 11, 2017, hearing before the Subcommittee on 
        Africa, Global Health, Global Human Rights, and 
        International Organizations on ``The State Department 
        and USAID FY 2018 Africa Budget'' (The Honorable Donald 
        Yamamoto, Acting Assistant Secretary, Bureau of African 
        Affairs, U.S. Department of State; Ms. Cheryl Anderson, 
        Acting Assistant Administrator, Bureau for Africa, 
        USAID);
          June 14, 2017, hearing before the full committee on 
        ``The FY 2018 Foreign Affairs Budget'' (The Honorable 
        Rex W. Tillerson, Secretary of State, U.S. Department 
        of State);
          May 18, 2017, hearing before the full committee on 
        ``U.S. Interests in Africa'' (General William E. Ward, 
        USA, Retired, President and Chief Operating Officer, 
        SENTEL Corporation and Former Commander, U.S. Africa 
        Command; Mr. Bryan Christy, Explorer and Investigative 
        Reporter, National Geographic Society; Mr. Anthony 
        Carroll, Adjunct Professor, School of Advanced 
        International Studies, Johns Hopkins University; the 
        Honorable Reuben E. Brigety II, Dean, Elliott School of 
        International Affairs, the George Washington University 
        and former U.S. Representative to the African Union, 
        U.S. Department of State);
          March 28, 2017, hearing before the full committee on 
        ``The Budget, Diplomacy, and Development'' (Stephen D. 
        Krasner, Ph.D., Senior Fellow, Hoover Institution; Ms. 
        Danielle Pletka, Senior Vice President, Foreign and 
        Defense Policy Studies, American Enterprise Institute; 
        the Honorable R. Nicholas Burns, Roy and Barbara 
        Goodman Family Professor of Diplomacy and International 
        Relations, Belfer Center for Science and International 
        Affairs, John F. Kennedy School of Government, Harvard 
        University and former Under Secretary for Political 
        Affairs, U.S. Department of State);
          December 8, 2015, hearing and briefing before the 
        Subcommittee on Africa, Global Health, Global Human 
        Rights, and International Organizations on ``Drug-
        Resistant Tuberculosis: The Next Global Health Crisis'' 
        (Tom Frieden, M.D., Director, CDC; the Honorable Ariel 
        Pablos-Mendez, M.D., Assistant Administrator Bureau for 
        Global Health, USAID; the Honorable Eric P. Goosby, 
        M.D., Special Envoy on Tuberculosis, United Nations and 
        former Global AIDS Coordinator, U.S. Department of 
        State);
          March 17, 2015, hearing before the full committee on 
        ``The FY 2016 Budget Request: Assessing U.S. Foreign 
        Assistance Effectiveness'' (Hon. Alfonso E. Lenhardt, 
        Acting Administrator, USAID; Hon. Dana J. Hyde, CEO, 
        Millennium Challenge Corporation);
          September 17, 2014, hearing before the Subcommittee 
        on Africa, Global Health, Global Human Rights, and 
        International Organizations on ``Global Efforts to 
        Fight Ebola'' (Anthony S. Fauci, M.D., Director, 
        National Institute of Allergy and Infectious Diseases, 
        HHS; Luciana Borio, M.D., Director, Office of 
        Counterterrorism and Emerging Threats, Office of the 
        Chief Scientist, U.S. Food and Drug Administration, 
        HHS; the Honorable Nancy Lindborg, Assistant 
        Administrator, Bureau for Democracy, Conflict and 
        Humanitarian Assistance, USAID; Beth P. Bell, M.D., 
        Director, National Center for Emerging and Zoonotic 
        Infectious Diseases, CDC; Kent Brantly, M.D., Medical 
        Missionary, Samaritan's Purse; Chinua Akukwe, M.D., 
        Chair, Africa Working Group, National Academy of Public 
        Administration; Mr. Ted Alemayhu, Founder & Executive 
        Chairman, U.S. Doctors for Africa; Dougbeh Chris Nyan, 
        M.D., Director of the Secretariat, Diaspora Liberian 
        Emergency Response Task Force on the Ebola Crisis); and
          August 7, 2014, hearing before the Subcommittee on 
        Africa, Global Health, Global Human Rights, and 
        International Organizations on ``Combatting the Ebola 
        Threat'' (Tom Frieden, M.D., Director, CDC; Ariel 
        Pablos-Mendez, M.D., Assistant Administrator, Bureau 
        for Global Health, USAID; the Honorable Bisa Williams, 
        Deputy Assistant Secretary, Bureau of African Affairs, 
        U.S. Department of State; Mr. Ken Isaacs, Vice 
        President of Program and Government Relations, 
        Samaritan's Purse; Frank Glover, M.D., Missionary, 
        SIM);
          April 9, 2014, hearing before the full committee on 
        ``U.S. Foreign Assistance in FY 2015: What Are the 
        Priorities, How Effective?'' (The Honorable Rajiv Shah, 
        Administrator, USAID).

                        Committee Consideration

    On September 22, 2018, the Foreign Affairs Committee marked 
up H.R. 6651 pursuant to notice, in open session. The chairman 
obtained unanimous consent to consider the bill en bloc with 
Smith 113, an amendment offered by Rep. Smith. The items 
considered en bloc were agreed to by voice vote. The committee 
ordered H.R. 6651, as amended, favorably reported by unanimous 
consent.

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII of Rules of 
the House of Representatives, the committee reports that 
findings and recommendations of the committee, based on 
oversight activities under clause 2(b)(1) of House Rule X, are 
incorporated in the descriptive portions of this report, 
particularly in the section on ``Background and Need for the 
Legislation.''

      New Budget Authority, Tax Expenditures, and Federal Mandates

    In compliance with clause 3(c)(2) of House Rule XIII and 
the Unfunded Mandates Reform Act (P.L. 104-4), the committee 
adopts as its own the estimate of new budget authority, 
entitlement authority, tax expenditure or revenues, and Federal 
mandates contained in the cost estimate prepared by the 
Director of the Congressional Budget Office pursuant to section 
402 of the Congressional Budget Act of 1974.

               Congressional Budget Office Cost Estimate

                                     U.S. Congress,
                               Congressional Budget Office,
                                  Washington, DC, October 11, 2018.

Hon. Edward R. Royce, Chairman,
Committee on Foreign Affairs,
House of Representatives, Washington, DC.

    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 6651, the PEPFAR 
Extension Act of 2018.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Ann E. 
Futrell, who can be reached at 226-2840.
            Sincerely,
                                                Keith Hall,
                                                          Director.
Enclosure

cc:
        Honorable Eliot L. Engel
        Ranking Member
H.R. 6651--PEPFAR Extension Act of 2018.

    As ordered reported by the House Committee on Foreign 
Affairs on September 27, 2018.

    H.R. 6651 would reauthorize, through 2023, certain expired 
provisions of foreign assistance programs to combat HIV/AIDS, 
malaria, and tuberculosis (commonly known as the U.S. 
President's Emergency Plan for AIDS Relief or PEPFAR). CBO 
estimates that implementing the bill would cost $15 million 
over the 2019-2023 period, assuming appropriation of the 
necessary amounts.
    Section 2 would extend through 2023 a requirement for the 
Inspectors General (IGs) of the Department of State and 
Broadcasting Board of Governors, the Department of Health and 
Human Services, and the U.S. Agency for International 
Development to coordinate and conduct oversight of PEPFAR 
programs. Under current law, that directive expired at the end 
of fiscal year 2018. According to the Office of the U.S. Global 
AIDS Coordinator (OGAC)--the office within the Department of 
State that coordinates all PEPFAR activities--the IGs spent 
roughly $15 million on such oversight over the past 5 years. 
CBO expects that each of the three IGs would require 
appropriations of roughly $1 million per year to continue such 
oversight. Thus, implementing that provision would cost $15 
million over the 2019-2023 period, CBO estimates.
    Section 2 also would extend through 2024 an annual 
requirement to provide a report on HIV/AIDS treatment 
providers. OGAC plans to collect and analyze the necessary 
information in the absence of this statutory requirement. CBO 
estimates that the additional costs of preparing the report 
would be less than $500,000 over the 2019-2023 period.
    Enacting H.R. 6651 would not affect direct spending or 
revenues; therefore, pay-as-you-go procedures do not apply.
    CBO estimates that enacting H.R. 6651 would not increase 
net direct spending or on-budget deficits in any of the four 
consecutive 10-year periods beginning in 2029.
    H.R. 6651 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act.
    On October 2, 2018, CBO transmitted a cost estimate for S. 
3476, the PEPFAR Extension Act of 2018, as ordered reported by 
the Senate Committee on Foreign Relations on September 26, 
2018. H.R. 6651 is similar to S. 3476, and their estimated 
costs are the same.
    The CBO staff contact for this estimate is Ann E. Futrell. 
The estimate was reviewed by Leo Lex, Deputy Assistant Director 
for Budget Analysis.

                          Directed Rule Making

    Pursuant to clause 3(c) of House Rule XIII, as modified by 
section 3(i) of H. Res. 5 during the 115th Congress, the 
committee notes that H.R. 6651 contains no directed rule-making 
provisions.

                  Non-Duplication of Federal Programs

    Pursuant to clause 3(c)(5) of House Rule XIII, the 
committee states that no provision of this bill establishes or 
reauthorizes a program of the Federal Government known to be 
duplicative of another Federal program, a program that was 
included in any report from the Government Accountability 
Office to Congress pursuant to section 21 of Public Law 111-
139, or a program related to a program identified in the most 
recent Catalog of Federal Domestic Assistance.

                    Performance Goals and Objectives

    The objective of this legislation is to extend and enhance 
U.S. efforts to combat AIDS, tuberculosis, and malaria through 
implementation of PEPFAR and participation in the Global Fund. 
Section 2 requires the Inspectors General of the U.S. 
Department of State, HHS, and USAID to develop joint auditing 
plans and requires the U.S. Global AIDS Coordinator to conduct 
annual studies of HIV/AIDS treatment providers and costs. These 
audits and studies will enable Congress to conduct effective 
oversight of performance and results.

                    Congressional Accountability Act

    H.R. 6651 does not apply to terms and conditions of 
employment or to access to public services or accommodations 
within the legislative branch.

                        New Advisory Committees

    H.R. 6651 does not establish or authorize any new advisory 
committees.

                         Earmark Identification

    H.R. 6651 contains no congressional earmarks, limited tax 
benefits, or limited tariff benefits as described in clauses 
9(e), 9(f), and 9(g) of House Rule XXI.

                      Section-by-Section Analysis

    Section 1. Short Title. States that the Act may be cited as 
the ``PEPFAR Extension Act of 2018.''
    Section 2. Inspectors General and Annual Study. Amends 
Section 101 of the United States Leadership Against HIV/AIDS, 
Tuberculosis, and Malaria Act of 2003 (22 U.S.C. 7611) to: (1) 
extend through Fiscal Year 2023 the requirement for the 
Inspectors General of the U.S. Department of State, HHS, and 
USAID to develop joint auditing plans; and (2) to extend 
through September 31, 2024 the requirement for the U.S. Global 
AIDS Coordinator to conduct annual studies of treatment 
providers and costs.
    Section 3. Participation in the Global Fund to Fight AIDS, 
Tuberculosis, and Malaria. Amends Section 202(d) of the United 
States Leadership Against HIV/AIDS, Tuberculosis, and Malaria 
Act of 2003 (22 U.S.C. 7622(d)) to: (1) extend through Fiscal 
Year 2023 the 33 percent cap on U.S. contributions to the 
Global Fund and clarify that the limitation applies to 
cumulative contributions between Fiscal Years 2004 and 2023; 
(2) extend through Fiscal Year 2023 a requirement to withhold 
contributions to the Global Fund in an amount equal to any 
assistance provided to a State Sponsor of Terrorism; and (3) 
clarify that any funds withheld from the Global Fund for any 
purpose may be made available for U.S. bilateral HIV/AIDS, 
tuberculosis, or malaria programs
    Section 4. Allocation of Funds. Amends Section 403 of the 
United States Leadership Against HIV/AIDS, Tuberculosis, and 
Malaria Act of 2003 (22 U.S.C. 7673) to extend through Fiscal 
Year 2023 the requirement to allocate at least 10 percent of 
the PEPFAR budget to programs that support children orphaned or 
made vulnerable by HIV/AIDS and at least half of the PEPFAR 
budget to HIV/AIDS treatment and care.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, and existing law in which no 
change is proposed is shown in roman):

 UNITED STATES LEADERSHIP AGAINST HIV/AIDS, TUBERCULOSIS, AND MALARIA 
                              ACT OF 2003



           *       *       *       *       *       *       *
               TITLE I--POLICY PLANNING AND COORDINATION

SEC. 101. DEVELOPMENT OF A COMPREHENSIVE, FIVE-YEAR, GLOBAL STRATEGY.

  (a) Strategy.--The President shall establish a comprehensive, 
integrated, 5-year strategy to expand and improve efforts to 
combat global HIV/AIDS. This strategy shall--
          (1) further strengthen the capability of the United 
        States to be an effective leader of the international 
        campaign against this disease and strengthen the 
        capacities of nations experiencing HIV/AIDS epidemics 
        to combat this disease;
          (2) maintain sufficient flexibility and remain 
        responsive to--
                  (A) changes in the epidemic;
                  (B) challenges facing partner countries in 
                developing and implementing an effective 
                national response; and
                  (C) evidence-based improvements and 
                innovations in the prevention, care, and 
                treatment of HIV/AIDS;
          (3) situate United States efforts to combat HIV/AIDS, 
        tuberculosis, and malaria within the broader United 
        States global health and development agenda, 
        establishing a roadmap to link investments in specific 
        disease programs to the broader goals of strengthening 
        health systems and infrastructure and to integrate and 
        coordinate HIV/AIDS, tuberculosis, or malaria programs 
        with other health or development programs, as 
        appropriate;
          (4) provide a plan to--
                  (A) prevent 12,000,000 new HIV infections 
                worldwide;
                  (B) support--
                          (i) the increase in the number of 
                        individuals with HIV/AIDS receiving 
                        antiretroviral treatment above the goal 
                        established under section 402(a)(3) and 
                        increased pursuant to paragraphs (1) 
                        through (3) of section 403(d); and
                          (ii) additional treatment through 
                        coordinated multilateral efforts;
                  (C) support care for 12,000,000 individuals 
                infected with or affected by HIV/AIDS, 
                including 5,000,000 orphans and vulnerable 
                children affected by HIV/AIDS, with an emphasis 
                on promoting a comprehensive, coordinated 
                system of services to be integrated throughout 
                the continuum of care;
                  (D) help partner countries in the effort to 
                achieve goals of 80 percent access to 
                counseling, testing, and treatment to prevent 
                the transmission of HIV from mother to child, 
                emphasizing a continuum of care model;
                  (E) help partner countries to provide care 
                and treatment services to children with HIV in 
                proportion to their percentage within the HIV-
                infected population in each country;
                  (F) promote preservice training for health 
                professionals designed to strengthen the 
                capacity of institutions to develop and 
                implement policies for training health workers 
                to combat HIV/AIDS, tuberculosis, and malaria;
                  (G) equip teachers with skills needed for 
                HIV/AIDS prevention and support for persons 
                with, or affected by, HIV/AIDS;
                  (H) provide and share best practices for 
                combating HIV/AIDS with health professionals;
                  (I) promote pediatric HIV/AIDS training for 
                physicians, nurses, and other health care 
                workers, through public-private partnerships if 
                possible, including through the designation, if 
                appropriate, of centers of excellence for 
                training in pediatric HIV/AIDS prevention, 
                care, and treatment in partner countries; and
                  (J) help partner countries to train and 
                support retention of health care professionals 
                and paraprofessionals, with the target of 
                training and retaining at least 140,000 new 
                health care professionals and paraprofessionals 
                with an emphasis on training and in country 
                deployment of critically needed doctors and 
                nurses and to strengthen capacities in 
                developing countries, especially in sub-Saharan 
                Africa, to deliver primary health care with the 
                objective of helping countries achieve staffing 
                levels of at least 2.3 doctors, nurses, and 
                midwives per 1,000 population, as called for by 
                the World Health Organization;
          (5) include multisectoral approaches and specific 
        strategies to treat individuals infected with HIV/AIDS 
        and to prevent the further transmission of HIV 
        infections, with a particular focus on the needs of 
        families with children (including the prevention of 
        mother-to-child transmission), women, young people, 
        orphans, and vulnerable children;
          (6) establish a timetable with annual global 
        treatment targets with country-level benchmarks for 
        antiretroviral treatment;
          (7) expand the integration of timely and relevant 
        research within the prevention, care, and treatment of 
        HIV/AIDS;
          (8) include a plan for program monitoring, operations 
        research, and impact evaluation and for the 
        dissemination of a best practices report to highlight 
        findings;
          (9) support the in-country or intra-regional 
        training, preferably through public-private 
        partnerships, of scientific investigators, managers, 
        and other staff who are capable of promoting the 
        systematic uptake of clinical research findings and 
        other evidence-based interventions into routine 
        practice, with the goal of improving the quality, 
        effectiveness, and local leadership of HIV/AIDS health 
        care;
          (10) expand and accelerate research on and 
        development of HIV/AIDS prevention methods for women, 
        including enhancing inter-agency collaboration, 
        staffing, and organizational infrastructure dedicated 
        to microbicide research;
          (11) provide for consultation with local leaders and 
        officials to develop prevention strategies and programs 
        that are tailored to the unique needs of each country 
        and community and targeted particularly toward those 
        most at risk of acquiring HIV infection;
          (12) make the reduction of HIV/AIDS behavioral risks 
        a priority of all prevention efforts by--
                  (A) promoting abstinence from sexual activity 
                and encouraging monogamy and faithfulness;
                  (B) encouraging the correct and consistent 
                use of male and female condoms and increasing 
                the availability of, and access to, these 
                commodities;
                  (C) promoting the delay of sexual debut and 
                the reduction of multiple concurrent sexual 
                partners;
                  (D) promoting education for discordant 
                couples (where an individual is infected with 
                HIV and the other individual is uninfected or 
                whose status is unknown) about safer sex 
                practices;
                  (E) promoting voluntary counseling and 
                testing, addiction therapy, and other 
                prevention and treatment tools for illicit 
                injection drug users and other substance 
                abusers;
                  (F) educating men and boys about the risks of 
                procuring sex commercially and about the need 
                to end violent behavior toward women and girls;
                  (G) supporting partner country and community 
                efforts to identify and address social, 
                economic, or cultural factors, such as 
                migration, urbanization, conflict, gender-based 
                violence, lack of empowerment for women, and 
                transportation patterns, which directly 
                contribute to the transmission of HIV;
                  (H) supporting comprehensive programs to 
                promote alternative livelihoods, safety, and 
                social reintegration strategies for commercial 
                sex workers and their families;
                  (I) promoting cooperation with law 
                enforcement to prosecute offenders of 
                trafficking, rape, and sexual assault crimes 
                with the goal of eliminating such crimes; and
                  (J) working to eliminate rape, gender-based 
                violence, sexual assault, and the sexual 
                exploitation of women and children;
          (13) include programs to reduce the transmission of 
        HIV, particularly addressing the heightened 
        vulnerabilities of women and girls to HIV in many 
        countries; and
          (14) support other important means of preventing or 
        reducing the transmission of HIV, including--
                  (A) medical male circumcision;
                  (B) the maintenance of a safe blood supply;
                  (C) promoting universal precautions in formal 
                and informal health care settings;
                  (D) educating the public to recognize and to 
                avoid risks to contract HIV through blood 
                exposures during formal and informal health 
                care and cosmetic services;
                  (E) investigating suspected nosocomial 
                infections to identify and stop further 
                nosocomial transmission; and
                  (F) other mechanisms to reduce the 
                transmission of HIV;
          (15) increase support for prevention of mother-to-
        child transmission;
          (16) build capacity within the public health sector 
        of developing countries by improving health systems and 
        public health infrastructure and developing indicators 
        to measure changes in broader public health sector 
        capabilities;
          (17) increase the coordination of HIV/AIDS programs 
        with development programs;
          (18) provide a framework for expanding or developing 
        existing or new country or regional programs, 
        including--
                  (A) drafting compacts or other agreements, as 
                appropriate;
                  (B) establishing criteria and objectives for 
                such compacts and agreements; and
                  (C) promoting sustainability;
          (19) provide a plan for national and regional 
        priorities for resource distribution and a global 
        investment plan by region;
          (20) provide a plan to address the immediate and 
        ongoing needs of women and girls, which--
                  (A) addresses the vulnerabilities that 
                contribute to their elevated risk of infection;
                  (B) includes specific goals and targets to 
                address these factors;
                  (C) provides clear guidance to field missions 
                to integrate gender across prevention, care, 
                and treatment programs;
                  (D) sets forth gender-specific indicators to 
                monitor progress on outcomes and impacts of 
                gender programs;
                  (E) supports efforts in countries in which 
                women or orphans lack inheritance rights and 
                other fundamental protections to promote the 
                passage, implementation, and enforcement of 
                such laws;
                  (F) supports life skills training, especially 
                among women and girls, with the goal of 
                reducing vulnerabilities to HIV/AIDS;
                  (G) addresses and prevents gender-based 
                violence; and
                  (H) addresses the posttraumatic and 
                psychosocial consequences and provides 
                postexposure prophylaxis protecting against HIV 
                infection to victims of gender-based violence 
                and rape;
          (21) provide a plan to--
                  (A) determine the local factors that may put 
                men and boys at elevated risk of contracting or 
                transmitting HIV;
                  (B) address male norms and behaviors to 
                reduce these risks, including by reducing 
                alcohol abuse;
                  (C) promote responsible male behavior; and
                  (D) promote male participation and leadership 
                at the community level in efforts to promote 
                HIV prevention, reduce stigma, promote 
                participation in voluntary counseling and 
                testing, and provide care, treatment, and 
                support for persons with HIV/AIDS;
          (22) provide a plan to address the vulnerabilities 
        and needs of orphans and children who are vulnerable 
        to, or affected by, HIV/AIDS;
          (23) encourage partner countries to develop health 
        care curricula and promote access to training tailored 
        to individuals receiving services through, or exiting 
        from, existing programs geared to orphans and 
        vulnerable children;
          (24) provide a framework to work with international 
        actors and partner countries toward universal access to 
        HIV/AIDS prevention, treatment, and care programs, 
        recognizing that prevention is of particular 
        importance;
          (25) enhance the coordination of United States 
        bilateral efforts to combat global HIV/AIDS with other 
        major public and private entities;
          (26) enhance the attention given to the national 
        strategic HIV/AIDS plans of countries receiving United 
        States assistance by--
                  (A) reviewing the planning and programmatic 
                decisions associated with that assistance; and
                  (B) helping to strengthen such national 
                strategies, if necessary;
          (27) support activities described in the Global Plan 
        to Stop TB, including--
                  (A) expanding and enhancing the coverage of 
                the Directly Observed Treatment Short-course 
                (DOTS) in order to treat individuals infected 
                with tuberculosis and HIV, including multi-drug 
                resistant or extensively drug resistant 
                tuberculosis; and
                  (B) improving coordination and integration of 
                HIV/AIDS and tuberculosis programming;
          (28) ensure coordination between the Global AIDS 
        Coordinator and the Malaria Coordinator and address 
        issues of comorbidity between HIV/AIDS and malaria; and
          (29) include a longer term estimate of the projected 
        resource needs, progress toward greater sustainability 
        and country ownership of HIV/AIDS programs, and the 
        anticipated role of the United States in the global 
        effort to combat HIV/AIDS during the 10-year period 
        beginning on October 1, 2013.
  (b) Report.--
          (1) In general.--Not later than October 1, 2009, the 
        President shall submit a report to the appropriate 
        congressional committees that sets forth the strategy 
        described in subsection (a).
          (2) Contents.--The report required under paragraph 
        (1) shall include a discussion of the following 
        elements:
                  (A) The purpose, scope, methodology, and 
                general and specific objectives of the 
                strategy.
                  (B) The problems, risks, and threats to the 
                successful pursuit of the strategy.
                  (C) The desired goals, objectives, 
                activities, and outcome-related performance 
                measures of the strategy.
                  (D) A description of future costs and 
                resources needed to carry out the strategy.
                  (E) A delineation of United States Government 
                roles, responsibility, and coordination 
                mechanisms of the strategy.
                  (F) A description of the strategy--
                          (i) to promote harmonization of 
                        United States assistance with that of 
                        other international, national, and 
                        private actors as elucidated in the 
                        ``Three Ones''; and
                          (ii) to address existing challenges 
                        in harmonization and alignment.
                  (G) A description of the manner in which the 
                strategy will--
                          (i) further the development and 
                        implementation of the national 
                        multisectoral strategic HIV/AIDS 
                        frameworks of partner governments; and
                          (ii) enhance the centrality, 
                        effectiveness, and sustainability of 
                        those national plans.
                  (H) A description of how the strategy will 
                seek to achieve the specific targets described 
                in subsection (a) and other targets, as 
                appropriate.
                  (I) A description of, and rationale for, the 
                timetable for annual global treatment targets 
                with country-level estimates of numbers of 
                persons in need of antiretroviral treatment, 
                country-level benchmarks for United States 
                support for assistance for antiretroviral 
                treatment, and numbers of persons enrolled in 
                antiretroviral treatment programs receiving 
                United States support. If global benchmarks are 
                not achieved within the reporting period, the 
                report shall include a description of steps 
                being taken to ensure that global benchmarks 
                will be achieved and a detailed breakdown and 
                justification of spending priorities in 
                countries in which benchmarks are not being 
                met, including a description of other donor or 
                national support for antiretroviral treatment 
                in the country, if appropriate.
                  (J) A description of how operations research 
                is addressed in the strategy and how such 
                research can most effectively be integrated 
                into care, treatment, and prevention activities 
                in order to--
                          (i) improve program quality and 
                        efficiency;
                          (ii) ascertain cost effectiveness;
                          (iii) ensure transparency and 
                        accountability;
                          (iv) assess population-based impact;
                          (v) disseminate findings and best 
                        practices; and
                          (vi) optimize delivery of services.
                  (K) An analysis of United States-assisted 
                strategies to prevent the transmission of HIV/
                AIDS, including methodologies to promote 
                abstinence, monogamy, faithfulness, the correct 
                and consistent use of male and female condoms, 
                reductions in concurrent sexual partners, and 
                delay of sexual debut, and of intended 
                monitoring and evaluation approaches to measure 
                the effectiveness of prevention programs and 
                ensure that they are targeted to appropriate 
                audiences.
                  (L) Within the analysis required under 
                subparagraph (K), an examination of additional 
                planned means of preventing the transmission of 
                HIV including medical male circumcision, 
                maintenance of a safe blood supply, public 
                education about risks to acquire HIV infection 
                from blood exposures, promotion of universal 
                precautions, investigation of suspected 
                nosocomial infections and other tools.
                  (M) A description of efforts to assist 
                partner country and community to identify and 
                address social, economic, or cultural factors, 
                such as migration, urbanization, conflict, 
                gender-based violence, lack of empowerment for 
                women, and transportation patterns, which 
                directly contribute to the transmission of HIV.
                  (N) A description of the specific targets, 
                goals, and strategies developed to address the 
                needs and vulnerabilities of women and girls to 
                HIV/AIDS, including--
                          (i) activities directed toward men 
                        and boys;
                          (ii) activities to enhance 
                        educational, microfinance, and 
                        livelihood opportunities for women and 
                        girls;
                          (iii) activities to promote and 
                        protect the legal empowerment of women, 
                        girls, and orphans and vulnerable 
                        children;
                          (iv) programs targeted toward gender-
                        based violence and sexual coercion;
                          (v) strategies to meet the particular 
                        needs of adolescents;
                          (vi) assistance for victims of rape, 
                        sexual abuse, assault, exploitation, 
                        and trafficking; and
                          (vii) programs to prevent alcohol 
                        abuse.
                  (O) A description of strategies to address 
                male norms and behaviors that contribute to the 
                transmission of HIV, to promote responsible 
                male behavior, and to promote male 
                participation and leadership in HIV/AIDS 
                prevention, care, treatment, and voluntary 
                counseling and testing.
                  (P) A description of strategies--
                          (i) to address the needs of orphans 
                        and vulnerable children, including an 
                        analysis of--
                                  (I) factors contributing to 
                                children's vulnerability to 
                                HIV/AIDS; and
                                  (II) vulnerabilities caused 
                                by the impact of HIV/AIDS on 
                                children and their families; 
                                and
                          (ii) in areas of higher HIV/AIDS 
                        prevalence, to promote a community-
                        based approach to vulnerability, 
                        maximizing community input into 
                        determining which children participate.
                  (Q) A description of capacity-building 
                efforts undertaken by countries themselves, 
                including adherents of the Abuja Declaration 
                and an assessment of the impact of 
                International Monetary Fund macroeconomic and 
                fiscal policies on national and donor 
                investments in health.
                  (R) A description of the strategy to--
                          (i) strengthen capacity building 
                        within the public health sector;
                          (ii) improve health care in those 
                        countries;
                          (iii) help countries to develop and 
                        implement national health workforce 
                        strategies;
                          (iv) strive to achieve goals in 
                        training, retaining, and effectively 
                        deploying health staff;
                          (v) promote the use of codes of 
                        conduct for ethical recruiting 
                        practices for health care workers; and
                          (vi) increase the sustainability of 
                        health programs.
                  (S) A description of the criteria for 
                selection, objectives, methodology, and 
                structure of compacts or other framework 
                agreements with countries or regional 
                organizations, including--
                          (i) the role of civil society;
                          (ii) the degree of transparency;
                          (iii) benchmarks for success of such 
                        compacts or agreements; and
                          (iv) the relationship between such 
                        compacts or agreements and the national 
                        HIV/AIDS and public health strategies 
                        and commitments of partner countries.
                  (T) A strategy to better coordinate HIV/AIDS 
                assistance with nutrition and food assistance 
                programs.
                  (U) A description of transnational or 
                regional initiatives to combat regionalized 
                epidemics in highly affected areas such as the 
                Caribbean.
                  (V) A description of planned resource 
                distribution and global investment by region.
                  (W) A description of coordination efforts in 
                order to better implement the Stop TB Strategy 
                and to address the problem of coinfection of 
                HIV/AIDS and tuberculosis and of projected 
                challenges or barriers to successful 
                implementation.
                  (X) A description of coordination efforts to 
                address malaria and comorbidity with malaria 
                and HIV/AIDS.
  (c) Study of Progress Toward Achievement of Policy 
Objectives.--
          (1) Design and budget plan for data evaluation.--The 
        Global AIDS Coordinator shall enter into a contract 
        with the Institute of Medicine of the National 
        Academies that provides that not later than 18 months 
        after the date of the enactment of the Tom Lantos and 
        Henry J. Hyde United States Global Leadership Against 
        HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act 
        of 2008, the Institute, in consultation with the Global 
        AIDS Coordinator and other relevant parties 
        representing the public and private sector, shall 
        provide the Global AIDS Coordinator with a design plan 
        and budget for the evaluation and collection of 
        baseline and subsequent data to address the elements 
        set forth in paragraph (2)(B). The Global AIDS 
        Coordinator shall submit the budget and design plan to 
        the appropriate congressional committees.
          (2) Study.--
                  (A) In general.--Not later than 4 years after 
                the date of the enactment of the Tom Lantos and 
                Henry J. Hyde United States Global Leadership 
                Against HIV/AIDS, Tuberculosis, and Malaria 
                Reauthorization Act of 2008, the Institute of 
                Medicine of the National Academies shall 
                publish a study that includes--
                          (i) an assessment of the performance 
                        of United States-assisted global HIV/
                        AIDS programs; and
                          (ii) an evaluation of the impact on 
                        health of prevention, treatment, and 
                        care efforts that are supported by 
                        United States funding, including 
                        multilateral and bilateral programs 
                        involving joint operations.
                  (B) Content.--The study conducted under this 
                paragraph shall include--
                          (i) an assessment of progress toward 
                        prevention, treatment, and care 
                        targets;
                          (ii) an assessment of the effects on 
                        health systems, including on the 
                        financing and management of health 
                        systems and the quality of service 
                        delivery and staffing;
                          (iii) an assessment of efforts to 
                        address gender-specific aspects of HIV/
                        AIDS, including gender related 
                        constraints to accessing services and 
                        addressing underlying social and 
                        economic vulnerabilities of women and 
                        men;
                          (iv) an evaluation of the impact of 
                        treatment and care programs on 5-year 
                        survival rates, drug adherence, and the 
                        emergence of drug resistance;
                          (v) an evaluation of the impact of 
                        prevention programs on HIV incidence in 
                        relevant population groups;
                          (vi) an evaluation of the impact on 
                        child health and welfare of 
                        interventions authorized under this Act 
                        on behalf of orphans and vulnerable 
                        children;
                          (vii) an evaluation of the impact of 
                        programs and activities authorized in 
                        this Act on child mortality; and
                          (viii) recommendations for improving 
                        the programs referred to in 
                        subparagraph (A)(i).
                  (C) Methodologies.--Assessments and impact 
                evaluations conducted under the study shall 
                utilize sound statistical methods and 
                techniques for the behavioral sciences, 
                including random assignment methodologies as 
                feasible. Qualitative data on process variables 
                should be used for assessments and impact 
                evaluations, wherever possible.
          (3) Contract authority.--The Institute of Medicine 
        may enter into contracts or cooperative agreements or 
        award grants to conduct the study under paragraph (2).
          (4) Authorization of appropriations.--There are 
        authorized to be appropriated such sums as may be 
        necessary to carry out the study under this subsection.
  (d) Comptroller General Report.--
          (1) Report required.--Not later than 3 years after 
        the date of the enactment of the Tom Lantos and Henry 
        J. Hyde United States Global Leadership Against HIV/
        AIDS, Tuberculosis, and Malaria Reauthorization Act of 
        2008, the Comptroller General of the United States 
        shall submit a report on the global HIV/AIDS programs 
        of the United States to the appropriate congressional 
        committees.
          (2) Contents.--The report required under paragraph 
        (1) shall include--
                  (A) a description and assessment of the 
                monitoring and evaluation practices and 
                policies in place for these programs;
                  (B) an assessment of coordination within 
                Federal agencies involved in these programs, 
                examining both internal coordination within 
                these programs and integration with the larger 
                global health and development agenda of the 
                United States;
                  (C) an assessment of procurement policies and 
                practices within these programs;
                  (D) an assessment of harmonization with 
                national government HIV/AIDS and public health 
                strategies as well as other international 
                efforts;
                  (E) an assessment of the impact of global 
                HIV/AIDS funding and programs on other United 
                States global health programming; and
                  (F) recommendations for improving the global 
                HIV/AIDS programs of the United States.
  (e) Best Practices Report.--
          (1) In general.--Not later than 1 year after the date 
        of the enactment of the Tom Lantos and Henry J. Hyde 
        United States Global Leadership Against HIV/AIDS, 
        Tuberculosis, and Malaria Reauthorization Act of 2008, 
        and annually thereafter, the Global AIDS Coordinator 
        shall publish a best practices report that highlights 
        the programs receiving financial assistance from the 
        United States that have the potential for replication 
        or adaption, particularly at a low cost, across global 
        AIDS programs, including those that focus on both 
        generalized and localized epidemics.
          (2) Dissemination of findings.--
                  (A) Publication on internet website.--The 
                Global AIDS Coordinator shall disseminate the 
                full findings of the annual best practices 
                report on the Internet website of the Office of 
                the Global AIDS Coordinator.
                  (B) Dissemination guidance.--The Global AIDS 
                Coordinator shall develop guidance to ensure 
                timely submission and dissemination of 
                significant information regarding best 
                practices with respect to global AIDS programs.
  (f) Inspectors General.--
          (1) Oversight plan.--
                  (A) Development.--The Inspectors General of 
                the Department of State and Broadcasting Board 
                of Governors, the Department of Health and 
                Human Services, and the United States Agency 
                for International Development shall jointly 
                develop coordinated annual plans for oversight 
                activity in each of the fiscal years 2009 
                through [2018] 2023, with regard to the 
                programs authorized under this Act and sections 
                104A, 104B, and 104C of the Foreign Assistance 
                Act of 1961 (22 U.S.C. 2151b-2, 2151b-3, and 
                2151b-4).
                  (B) Contents.--The plans developed under 
                subparagraph (A) shall include a schedule for 
                financial audits, inspections, and performance 
                reviews, as appropriate.
                  (C) Deadline.--
                          (i) Initial plan.--The first plan 
                        developed under subparagraph (A) shall 
                        be completed not later than the later 
                        of--
                                  (I) September 1, 2008; or
                                  (II) 60 days after the date 
                                of the enactment of the Tom 
                                Lantos and Henry J. Hyde United 
                                States Global Leadership 
                                Against HIV/AIDS, Tuberculosis, 
                                and Malaria Reauthorization Act 
                                of 2008.
                          (ii) 2010 through 2013 plans.--Each 
                        of the plans for fiscal years 2010 
                        through 2013 developed under 
                        subparagraph (A) shall be completed not 
                        later than 30 days before each of the 
                        fiscal years 2010 through 2013, 
                        respectively.
                          (iii) 2014 plan.--The plan developed 
                        under subparagraph (A) for fiscal year 
                        2014 shall be completed not later than 
                        60 days after the date of the enactment 
                        of the PEPFAR Stewardship and Oversight 
                        Act of 2013.
                          (iv) Subsequent plans.--Each of the 
                        last [four] nine plans developed under 
                        subparagraph (A) shall be completed not 
                        later than 30 days before each of the 
                        fiscal years 2015 through [2018] 2023 , 
                        respectively.
          (2) Coordination.--In order to avoid duplication and 
        maximize efficiency, the Inspectors General described 
        in paragraph (1) shall coordinate their activities 
        with--
                  (A) the Government Accountability Office; and
                  (B) the Inspectors General of the Department 
                of Commerce, the Department of Defense, the 
                Department of Labor, and the Peace Corps, as 
                appropriate, pursuant to the 2004 Memorandum of 
                Agreement Coordinating Audit Coverage of 
                Programs and Activities Implementing the 
                President's Emergency Plan for AIDS Relief, or 
                any successor agreement.
          (3) Funding.--The Global AIDS Coordinator and the 
        Coordinator of the United States Government Activities 
        to Combat Malaria Globally shall make available 
        necessary funds not exceeding $15,000,000 during the 5-
        year period beginning on October 1, 2008 to the 
        Inspectors General described in paragraph (1) for the 
        audits, inspections, and reviews described in that 
        paragraph.
  (g) Annual Study.--
          (1) In general.--Not later than September 30, 2009, 
        and annually thereafter through September 30, [2019] 
        2024 , the Global AIDS Coordinator shall complete a 
        study of treatment providers that--
                  (A) represents a range of countries and 
                service environments;
                  (B) estimates the per-patient cost of 
                antiretroviral HIV/AIDS treatment and the care 
                of people with HIV/AIDS not receiving 
                antiretroviral treatment, including a 
                comparison of the costs for equivalent services 
                provided by programs not receiving assistance 
                under this Act;
                  (C) estimates per-patient costs across the 
                program and in specific categories of service 
                providers, including--
                          (i) urban and rural providers;
                          (ii) country-specific providers; and
                          (iii) other subcategories, as 
                        appropriate.
          (2) 2013 through [2018] 2024 studies.--The studies 
        required to be submitted by September 30, 2014, and 
        annually thereafter through [September 30, 2018] 
        September 30, 2024, shall include, in addition to the 
        elements set forth under paragraph (1), the following 
        elements:
                  (A) A plan for conducting cost studies of 
                United States assistance under section 104A of 
                the Foreign Assistance Act of 1961 (22 U.S.C. 
                2151b-2) in partner countries, taking into 
                account the goal for more systematic collection 
                of data, as well as the demands of such 
                analysis on available human and fiscal 
                resources.
                  (B) A comprehensive and harmonized 
                expenditure analysis by partner country, 
                including--
                          (i) an analysis of Global Fund and 
                        national partner spending and 
                        comparable data across United States, 
                        Global Fund, and national partner 
                        spending; or
                          (ii) where providing such comparable 
                        data is not currently practicable, an 
                        explanation of why it is not currently 
                        practicable, and when it will be 
                        practicable.
          (3) Publication.--Not later than 90 days after the 
        completion of each study under paragraph (1), the 
        Global AIDS Coordinator shall make the results of such 
        study available on a publicly accessible Web site.
          (4) Partner country defined.--In this subsection, the 
        term ``partner country'' means a country with a minimum 
        United States Government investment of HIV/AIDS 
        assistance of at least $5,000,000 in the prior fiscal 
        year.
  (h) Message.--The Global AIDS Coordinator shall develop a 
message, to be prominently displayed by each program receiving 
funds under this Act, that--
          (1) demonstrates that the program is a commitment by 
        citizens of the United States to the global fight 
        against HIV/AIDS, tuberculosis, and malaria; and
          (2) enhances awareness by program recipients that the 
        program is an effort on behalf of the citizens of the 
        United States.

           *       *       *       *       *       *       *


TITLE II--SUPPORT FOR MULTILATERAL FUNDS, PROGRAMS, AND PUBLIC-PRIVATE 
PARTNERSHIPS

           *       *       *       *       *       *       *


SEC. 202. PARTICIPATION IN THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS 
                    AND MALARIA.

  (a) Findings; Sense of Congress.--
          (1) Findings.--Congress makes the following findings:
                  (A) The establishment of the Global Fund in 
                January 2002 is consistent with the general 
                principles for an international AIDS trust fund 
                first outlined by Congress in the Global AIDS 
                and Tuberculosis Relief Act of 2000 (Public Law 
                106-264).
                  (B) The Global Fund is an innovative 
                financing mechanism which--
                          (i) has made progress in many areas 
                        in combating HIV/AIDS, tuberculosis, 
                        and malaria; and
                          (ii) represents the multilateral 
                        component of this Act, extending United 
                        States efforts to more than 130 
                        countries around the world.
                  (C) The Global Fund and United States 
                bilateral assistance programs--
                          (i) are demonstrating increasingly 
                        effective coordination, with each 
                        possessing certain comparative 
                        advantages in the fight against HIV/
                        AIDS, tuberculosis, and malaria; and
                          (ii) often work most effectively in 
                        concert with each other.
                  (D) The United States Government--
                          (i) is the largest supporter of the 
                        Global Fund in terms of resources and 
                        technical support;
                          (ii) made the founding contribution 
                        to the Global Fund; and
                          (iii) is fully committed to the 
                        success of the Global Fund as a 
                        multilateral public-private 
                        partnership.
          (2) Sense of congress.--It is the sense of Congress 
        that--
                  (A) transparency and accountability are 
                crucial to the long-term success and viability 
                of the Global Fund;
                  (B) the Global Fund has made significant 
                progress toward addressing concerns raised by 
                the Government Accountability Office by--
                          (i) improving risk assessment and 
                        risk management capabilities;
                          (ii) providing clearer guidance for 
                        and oversight of Local Fund Agents; and
                          (iii) strengthening the Office of the 
                        Inspector General for the Global Fund;
                  (C) the provision of sufficient resources and 
                authority to the Office of the Inspector 
                General for the Global Fund to ensure that 
                office has the staff and independence necessary 
                to carry out its mandate will be a measure of 
                the commitment of the Global Fund to 
                transparency and accountability;
                  (D) regular, publicly published financial, 
                programmatic, and reporting audits of the Fund, 
                its grantees, and Local Fund Agents are also 
                important benchmarks of transparency;
                  (E) the Global Fund should establish and 
                maintain a system to track--
                          (i) the amount of funds disbursed to 
                        each subrecipient on the grant's fiscal 
                        cycle; and
                          (ii) the distribution of resources, 
                        by grant and principal recipient, for 
                        prevention, care, treatment, drug and 
                        commodity purchases, and other 
                        purposes;
                  (F) relevant national authorities in 
                recipient countries should exempt from duties 
                and taxes all products financed by Global Fund 
                grants and procured by any principal recipient 
                or subrecipient for the purpose of carrying out 
                such grants;
                  (G) the Global Fund, UNAIDS, and the Global 
                AIDS Coordinator should work together to 
                standardize program indicators wherever 
                possible;
                  (H) for purposes of evaluating total amounts 
                of funds contributed to the Global Fund under 
                subsection (d)(4)(A)(i), the timetable for 
                evaluations of contributions from sources other 
                than the United States should take into account 
                the fiscal calendars of other major 
                contributors; and
                  (I) the Global Fund should not support 
                activities involving the ``Affordable Medicines 
                Facility-Malaria'' or similar entities pending 
                compelling evidence of success from pilot 
                programs as evaluated by the Coordinator of 
                United States Government Activities to Combat 
                Malaria Globally.
  (b) Authority for United States Participation.--
          (1) United states participation.--The United States 
        is hereby authorized to participate in the Global Fund.
          (2) Privileges and immunities.--The Global Fund shall 
        be considered a public international organization for 
        purposes of section 1 of the International 
        Organizations Immunities Act (22 U.S.C. 288).
          (3) Statement of policy.--The United States 
        Government regards the imposition by recipient 
        countries of taxes or tariffs on goods or services 
        provided by the Global Fund, which are supported 
        through public and private donations, including the 
        substantial contribution of the American people, as 
        inappropriate and inconsistent with standards of good 
        governance. The Global AIDS Coordinator or other 
        representatives of the United States Government shall 
        work with the Global Fund to dissuade governments from 
        imposing such duties, tariffs, or taxes.
  (c) Reports to Congress.--Not later than 1 year after the 
date of the enactment of this Act, and annually thereafter for 
the duration of the Global Fund, the President shall submit to 
the appropriate congressional committees a report on the Global 
Fund, including contributions pledged to, contributions 
(including donations from the private sector) received by, and 
projects funded by the Global Fund, and the mechanisms 
established for transparency and accountability in the grant-
making process.
  (d) United States Financial Participation.--
          (1) Authorization of appropriations.--In addition to 
        any other funds authorized to be appropriated for 
        bilateral or multilateral HIV/AIDS, tuberculosis, or 
        malaria programs, of the amounts authorized to be 
        appropriated under section 401, there are authorized to 
        be appropriated to the President up to $2,000,000,000 
        for fiscal year 2009,, and such sums as may be 
        necessary for each of the fiscal years 2010 through 
        2013, for contributions to the Global Fund.
          (2) Availability of funds.--Amounts appropriated 
        under paragraph (1) are authorized to remain available 
        until expended.
          (3) Reprogramming of fiscal year 2001 funds.--Funds 
        made available for fiscal year 2001 under section 141 
        of the Global AIDS and Tuberculosis Relief Act of 
        2000--
                  (A) are authorized to remain available until 
                expended; and
                  (B) shall be transferred to, merged with, and 
                made available for the same purposes as, funds 
                made available for fiscal years 2004 through 
                2008 under paragraph (1).
          (4) Limitation.--
                  (A)(i) At any time during [fiscal years 2009 
                through 2018] fiscal years 2004 through 2023 , 
                no United States contribution to the Global 
                Fund may cause the total amount of United 
                States Government contributions to the Global 
                Fund to exceed 33 percent of the total amount 
                of funds contributed to the Global Fund from 
                all sources. Contributions to the Global Fund 
                from the International Bank for Reconstruction 
                and Development and the International Monetary 
                Fund shall not be considered in determining 
                compliance with this paragraph.
                  (ii) If, at any time during any of the fiscal 
                years 2009 through [2018] 2023 , the President 
                determines that the Global Fund has provided 
                assistance to a country, the government of 
                which the Secretary of State has determined, 
                for purposes of section 6(j)(1) of the Export 
                Administration Act of 1979 (50 U.S.C. App. 
                2405(j)(1)), has repeatedly provided support 
                for acts of international terrorism, then the 
                United States shall withhold from its 
                contribution for the next fiscal year an amount 
                equal to the amount expended by the Fund to the 
                government of each such country.
                  (iii) If at any time the President determines 
                that the expenses of the Governing, 
                Administrative, and Advisory Bodies (including 
                the Partnership Forum, the Foundation Board, 
                the Secretariat, and the Technical Review 
                Board) of the Global Fund exceed 10 percent of 
                the total expenditures of the Fund for any 2-
                year period, the United States shall withhold 
                from its contribution for the next fiscal year 
                an amount equal the to the average annual 
                amount expended by the Fund for such 2-year 
                period for the expenses of the Governing, 
                Administrative, and Advisory Bodies in excess 
                of 10 percent of the total expenditures of the 
                Fund.
                  (iv) The President may waive the application 
                of clause (iii) if the President determines 
                that extraordinary circumstances warrant such a 
                waiver. No waiver under this clause may be for 
                any period that exceeds 1 year.
                  (v) If, at any time during any of the fiscal 
                years 2004 through 2008, the President 
                determines that the salary of any individual 
                employed by the Global Fund exceeds the salary 
                of the Vice President of the United States (as 
                determined under section 104 of title 3, United 
                States Code) for that fiscal year, then the 
                United States shall withhold from its 
                contribution for the next fiscal year an amount 
                equal to the aggregate amount by which the 
                salary of each such individual exceeds the 
                salary of the Vice President of the United 
                States.
                  [(vi) For the purposes of clause (i), ``funds 
                contributed to the Global Fund from all 
                sources'' means funds contributed to the Global 
                Fund at any time during fiscal years 2009 
                through 2018 that are not contributed to 
                fulfill a commitment made for a fiscal year 
                before fiscal year 2009.]
                  (B)(i) Any amount made available that is 
                withheld by reason of subparagraph (A)(i) shall 
                be contributed to the Global Fund as soon as 
                practicable, subject to subparagraph (A)(i), 
                after additional contributions to the Global 
                Fund are made from other sources.
                  [(ii) Any amount made available that is 
                withheld by reason of subparagraph (A)(iii) 
                shall be transferred to the Activities to 
                Combat HIV/AIDS Globally Fund and shall remain 
                available under the same terms and conditions 
                as funds appropriated to carry out section 104A 
                of the Foreign Assistance Act of 1961 for HIV/
                AIDS assistance.]
                  [(iii)] (ii) Any amount made available that 
                is withheld by reason of clause (ii) or (iii) 
                of subparagraph (A) is authorized to be made 
                available to carry out section 104A of the 
                Foreign Assistance Act of 1961 (as added by 
                section 301 of this Act) or section 104B or 
                104C of such Act . Amounts made available under 
                the preceding sentence are in addition to 
                amounts appropriated pursuant to the 
                authorization of appropriations under section 
                401 of this Act [for HIV/AIDS assistance].
                  [(iv)] (iii) Notwithstanding clause (i), 
                after July 31 of each of the fiscal years 2009 
                through [2018] 2023 , any amount made available 
                that is withheld by reason of 
                subparagraph(A)(i) is authorized to be made 
                available to carry out sections 104A, 104B, and 
                104C of the Foreign Assistance Act of 1961 (as 
                added by title III of this Act).
                  (C)(i) The President may suspend the 
                application of subparagraph (A) with respect to 
                a fiscal year if the President determines that 
                an international health emergency threatens the 
                national security interests of the United 
                States.
                  (ii) The President shall notify the Committee 
                on Foreign Affairs of the House of 
                Representatives and the Committee on Foreign 
                Relations of the Senate not less than 5 days 
                before making a determination under clause (i) 
                with respect to the application of subparagraph 
                (A)(i) and shall include in the notification--
                          (I) a justification as to why 
                        increased United States Government 
                        contributions to the Global Fund is 
                        preferable to increased United States 
                        assistance to combat HIV/AIDS, 
                        tuberculosis, and malaria on a 
                        bilateral basis; and
                          (II) an explanation as to why other 
                        government donors to the Global Fund 
                        are unable to provide adequate 
                        contributions to the Fund.
          (5) Withholding funds.--Notwithstanding any other 
        provision of this Act, 20 percent of the amounts 
        appropriated pursuant to this Act for a contribution to 
        support the Global Fund for each of the fiscal years 
        2010 through [2018] 2023 shall be withheld from 
        obligation to the Global Fund until the Secretary of 
        State certifies to the appropriate congressional 
        committees that the Global Fund--
                  (A) has established an evaluation framework 
                for the performance of Local Fund Agents 
                (referred to in this paragraph as ``LFAs'');
                  (B) is undertaking a systematic assessment of 
                the performance of LFAs;
                  (C) has adopted, and is implementing, a 
                policy to publish on a publicly available Web 
                site in an open, machine readable format--
                          (i) grant performance reviews;
                          (ii) all reports of the Inspector 
                        General of the Global Fund, in a manner 
                        that is consistent with the Policy for 
                        Disclosure of Reports of the Inspector 
                        General, approved at the 16th Meeting 
                        of the Board of the Global Fund;
                          (iii) decision points of the Board of 
                        the Global Fund;
                          (iv) reports from Board committees to 
                        the Board; and
                          (v) aregular collection, analysis, 
                        and reporting of performance data and 
                        funding ofgrants of the Global Fund, 
                        which covers all principal recipients 
                        and allsubrecipients on the fiscal 
                        cycle of each grant, and includes the 
                        distributionof resources, by grant and 
                        principal recipient and subrecipient, 
                        forprevention, care, treatment, drugs, 
                        and commodities purchase, and 
                        otherpurposes aspracticable;
                  (D) is maintaining an independent, well-
                staffed Office of the Inspector General that--
                          (i) reports directly to the Board of 
                        the Global Fund; and
                          (ii) compiles regular, publicly 
                        published audits, in an open, machine 
                        readable format, of financial, 
                        programmatic, and reporting aspects of 
                        the Global Fund, its grantees, and 
                        LFAs;
                  (E) has established, and is reporting 
                publicly, in an open, machine readable format, 
                on, standard indicators for all program areas;
                  (F) has established a methodology to track 
                and is publicly reporting on--
                          (i) all subrecipients and the amount 
                        of funds disbursed to each subrecipient 
                        on the grant's fiscal cycle;
                          (ii) all principalrecipients and 
                        subrecipients and the amount of funds 
                        disbursed to eachprincipal recipient 
                        and subrecipient on the fiscal cycle of 
                        the grant;
                          (iii) expendituredata--
                                  (I) tracked byprincipal 
                                recipients and subrecipients by 
                                program area, where 
                                practicable, prevention, care, 
                                and treatment and reported in a 
                                format that allows comparison 
                                with other fundingstreams in 
                                each country; or
                                  (II) if suchexpenditure data 
                                is not available, outlay or 
                                disbursement data, and 
                                anexplanation of progress made 
                                toward providing such 
                                expenditure data; and
                          (iv) high-qualitygrant performance 
                        evaluations measuring inputs, outputs, 
                        and outcomes, asappropriate, with the 
                        goal of achieving outcomereporting;
                  (G) has published anannual report on a 
                publicly available Web site in an open, machine 
                readableformat, that includes--
                          (i) alist of all countries imposing 
                        import duties and internal taxes on any 
                        goods orservices financed by the Global 
                        Fund;
                          (ii) a description ofthe types of 
                        goods or services on which the import 
                        duties and internal taxesare levied;
                          (iii) the total costof the import 
                        duties and internal taxes;
                          (iv) recovered importduties or 
                        internal taxes; and
                          (v) the status ofcountrystatus-
                        agreements;
                  (H) through its Secretariat, has taken 
                meaningful steps to prevent national 
                authorities in recipient countries from 
                imposing taxes or tariffs on goods or services 
                provided by the Fund;
                  (I) is maintaining its status as a financing 
                institution focused on programs directly 
                related to HIV/AIDS, malaria, and tuberculosis;
                  (J) is maintaining and making progress on--
                          (i) sustaining its multisectoral 
                        approach, through country coordinating 
                        mechanisms; and
                          (ii) the implementation of grants, as 
                        reflected in the proportion of 
                        resources allocated to different 
                        sectors, including governments, civil 
                        society, and faith- and community-based 
                        organizations; and
                  (K) has established procedures providing 
                access by the Office of Inspector General of 
                the Department of State and Broadcasting Board 
                of Governors, as cognizant Inspector General, 
                and the Inspector General of the Health and 
                Human Services and the Inspector General of the 
                United States Agency for International 
                Development, to Global Fund financial data, and 
                other information relevant to United States 
                contributions (as determined by the Inspector 
                General in consultation with the Global AIDS 
                Coordinator).
          (6) Summaries of board decisions and united states 
        positions.--Following each meeting of the Board of the 
        Global Fund, the Coordinator of United States 
        Government Activities to Combat HIV/AIDS Globally shall 
        report on the public website of the Coordinator a 
        summary of Board decisions and how the United States 
        Government voted and its positions on such decisions.
  (e) Interagency Technical Review Panel.--
          (1) Establishment.--The Coordinator of United States 
        Government Activities to Combat HIV/AIDS Globally, 
        established in section 1(f)(1) of the State Department 
        Basic Authorities Act of 1956 (as added by section 
        102(a) of this Act), shall establish in the executive 
        branch an interagency technical review panel.
          (2) Duties.--The interagency technical review panel 
        shall serve as a ``shadow'' panel to the Global Fund 
        by--
                  (A) periodically reviewing all proposals 
                received by the Global Fund; and
                  (B) providing guidance to the United States 
                persons who are representatives on the panels, 
                committees, and boards of the Global Fund, on 
                the technical efficacy, suitability, and 
                appropriateness of the proposals, and ensuring 
                that such persons are fully informed of 
                technical inadequacies or other aspects of the 
                proposals that are inconsistent with the 
                purposes of this or any other Act relating to 
                the provision of foreign assistance in the area 
                of AIDS.
          (3) Membership.--The interagency technical review 
        panel shall consist of qualified medical and 
        development experts who are officers or employees of 
        the Department of Health and Human Services, the 
        Department of State, and the United States Agency for 
        International Development.
          (4) Chair.--The Coordinator referred to in paragraph 
        (1) shall chair the interagency technical review panel.
  (f) Monitoring by Comptroller General.--
          (1) Monitoring.--The Comptroller General shall 
        monitor and evaluate projects funded by the Global 
        Fund.
          (2) Report.--The Comptroller General shall on a 
        biennial basis shall prepare and submit to the 
        appropriate congressional committees a report that 
        contains the results of the monitoring and evaluation 
        described in paragraph (1) for the preceding 2-year 
        period.
  (g) Provision of Information to Congress.--The Coordinator of 
United States Government Activities to Combat HIV/AIDS Globally 
shall make available to the Congress the following documents 
within 30 days of a request by the Congress for such documents:
          (1) All financial and accounting statements for the 
        Global Fund and the Activities to Combat HIV/AIDS 
        Globally Fund, including administrative and grantee 
        statements.
          (2) Reports provided to the Global Fund and the 
        Activities to Combat HIV/AIDS Globally Fund by 
        organizations contracted to audit recipients of funds.
          (3) Project proposals submitted by applicants for 
        funding from the Global Fund and the Activities to 
        Combat HIV/AIDS Globally Fund, but which were not 
        funded.
          (4) Progress reports submitted to the Global Fund and 
        the Activities to Combat HIV/AIDS Globally Fund by 
        grantees.
  (h) Sense of the Congress Regarding Encouragement of Private 
Contributions to the Global Fund.--It is the sense of the 
Congress that the President should--
          (1) conduct an outreach campaign that is designed 
        to--
                  (A) inform the public of the existence of--
                          (i) the Global Fund; and
                          (ii) any entity that will accept 
                        private contributions intended for use 
                        by the Global Fund; and
                  (B) encourage private contributions to the 
                Global Fund; and
          (2) encourage private contributions intended for use 
        by the Global Fund by--
                  (A) establishing and operating an Internet 
                website, and publishing information about the 
                website; and
                  (B) making public service announcements on 
                radio and television.

           *       *       *       *       *       *       *


TITLE IV--AUTHORIZATION OF APPROPRIATIONS

           *       *       *       *       *       *       *


SEC. 403. ALLOCATION OF FUNDS.

  (a) Balanced Funding Requirement.--
          (1) In general.--The Global AIDS Coordinator shall--
                  (A) provide balanced funding for prevention 
                activities for sexual transmission of HIV/AIDS; 
                and
                  (B) ensure that activities promoting 
                abstinence, delay of sexual debut, monogamy, 
                fidelity, and partner reduction are implemented 
                and funded in a meaningful and equitable way in 
                the strategy for each host country based on 
                objective epidemiological evidence as to the 
                source of infections and in consultation with 
                the government of each host county involved in 
                HIV/AIDS prevention activities.
          (2) Prevention strategy.--
                  (A) Establishment.--In carrying out paragraph 
                (1), the Global AIDS Coordinator shall 
                establish an HIV sexual transmission prevention 
                strategy governing the expenditure of funds 
                authorized under this Act to prevent the sexual 
                transmission of HIV in any host country with a 
                generalized epidemic.
                  (B) Report.--In each host country described 
                in subparagraph (A), if the strategy 
                established under subparagraph (A) provides 
                less than 50 percent of the funds described in 
                subparagraph (A) for activities promoting 
                abstinence, delay of sexual debut, monogamy, 
                fidelity, and partner reduction, the Global 
                AIDS Coordinator shall, not later than 30 days 
                after the issuance of this strategy, report to 
                the appropriate congressional committees on the 
                justification for this decision.
          (3) Exclusion.--Programs and activities that 
        implement or purchase new prevention technologies or 
        modalities, such as medical male circumcision, public 
        education about risks to acquire HIV infection from 
        blood exposures, promoting universal precautions, 
        investigating suspected nosocomial infections, pre-
        exposure pharmaceutical prophylaxis to prevent 
        transmission of HIV, or microbicides and programs and 
        activities that provide counseling and testing for HIV 
        or prevent mother-to-child prevention of HIV, shall not 
        be included in determining compliance with paragraph 
        (2).
          (4) Report.--Not later than 1 year after the date of 
        the enactment of the Tom Lantos and Henry J. Hyde 
        United States Global Leadership Against HIV/AIDS, 
        Tuberculosis, and Malaria Reauthorization Act of 2008, 
        and annually thereafter as part of the annual report 
        required under section 104A(e) of the Foreign 
        Assistance Act of 1961 (22 U.S.C. 2151b-2(e)), the 
        President shall--
                  (A) submit a report on the implementation of 
                paragraph (2) for the most recently concluded 
                fiscal year to the appropriate congressional 
                committees; and
                  (B) make the report described in subparagraph 
                (A) available to the public.
  (b) Orphans and Vulnerable Children.--For fiscal years 2009 
through [2018] 2023 , not less than 10 percent of the amounts 
appropriated or otherwise made available to carry out the 
provisions of section 104A of the Foreign Assistance Act of 
1961 (22 U.S.C. 2151b-2) for HIV/AIDS assistance for each such 
fiscal year shall be expended for assistance for orphans and 
other children affected by, or vulnerable to, HIV/AIDS, of 
which such amount at least 50 percent shall be provided through 
non-profit, nongovernmental organizations, including faith-
based organizations, that implement programs on the community 
level.
  (c) Funding Allocation.--For each of the fiscal years 2009 
through [2018] 2023 , more than half of the amounts 
appropriated or otherwise made available to carry out the 
provisions of section 104A of the Foreign Assistance Act of 
1961 (22 U.S.C. 2151b-2) shall be expended for--
          (1) antiretroviral treatment for HIV/AIDS;
          (2) clinical monitoring of HIV-seropositive people 
        not in need of antiretroviral treatment;
          (3) care for associated opportunistic infections;
          (4) nutrition and food support for people living with 
        HIV/AIDS; and
          (5) other essential HIV/AIDS-related medical care for 
        people living with HIV/AIDS.
  (d) Treatment, Prevention, and Care Goals.--For each of the 
fiscal years 2009 through 2013--
          (1) the treatment goal under section 402(a)(3) shall 
        be increased above 2,000,000 by at least the percentage 
        increase in the amount appropriated for bilateral 
        global HIV/AIDS assistance for such fiscal year 
        compared with fiscal year 2008;
          (2) any increase in the treatment goal under section 
        402(a)(3) above the percentage increase in the amount 
        appropriated for bilateral global HIV/AIDS assistance 
        for such fiscal year compared with fiscal year 2008 
        shall be based on long-term requirements, 
        epidemiological evidence, the share of treatment needs 
        being met by partner governments and other sources of 
        treatment funding, and other appropriate factors;
          (3) the treatment goal under section 402(a)(3) shall 
        be increased above the number calculated under 
        paragraph (1) by the same percentage that the average 
        United States Government cost per patient of providing 
        treatment in countries receiving bilateral HIV/AIDS 
        assistance has decreased compared with fiscal year 
        2008; and
          (4) the prevention and care goals established in 
        clauses (i) and (iv) of section 104A(b)(1)(A) of the 
        Foreign Assistance Act of 1961 (22 U.S.C. 2151b-
        2(b)(1)(A)) shall be increased consistent with 
        epidemiological evidence and available resources.

           *       *       *       *       *       *       *


                            ADDITIONAL VIEWS

    I concur with the views expressed in the full Committee 
report accompanying H.R. 6651, the PEPFAR Extension Act of 2018 
and recommend that the bill as amended do pass.
    The President's Emergency Plan for AIDS Relief (PEPFAR) has 
brought about tremendous progress across the Bush and Obama 
Administrations in the global fight to end HIV/AIDS, as 
detailed in the full Committee report. However, the Trump 
Administration has threatened this progress by asking Congress 
to enact deep funding cuts and impeding health care access 
through the reinstatement and expansion of the Mexico City 
Policy, or Global Gag Rule.
Draconian Cuts to PEPFAR and the Global Fund Jeopardize 15 Years of 
        Progress
    The Administration proposed an 11 percent cut to PEPFAR 
funding and a 17 percent cut to the Global Fund for Fiscal Year 
(FY) 2018, relative to FY 2017 levels. While Congress rejected 
this proposal and maintained level funding for both PEPFAR and 
the Global Fund, the Trump Administration subsequently 
requested an even deeper 20 percent cut to PEPFAR and 31 
percent cut to the Global Fund for FY 2019.
    If enacted, the Trump Administration's budget would 
jeopardize America's tremendous success in the fight against 
HIV/AIDS, likely leading to hundreds of thousands of additional 
HIV/AIDS patients and thousands of deaths. According to a 
report issued by the ONE Campaign:

          Conservative estimates project that implementing the 
        FY 2018 budget proposal would have led to the first 
        global increase in new HIV infections since 1995, with 
        nearly 200,000 additional HIV infections in the first 
        year. If these cuts were maintained, nearly 600,000 
        additional people could be infected by 2020, dragging 
        the world back to levels of new infections last seen in 
        2011. Slowing U.S. efforts to fight HIV/AIDS for three 
        years could set the global response back nine years and 
        squander much of the $64 billion that the U.S. has 
        invested over that time.\1\
---------------------------------------------------------------------------
    \1\``Red Ribbon or White Flag? The Future of the U.S. Global AIDS 
Response.'' The ONE Campaign. November 29, 2017. https://
s3.amazonaws.com/one.org/pdfs/ONE_WAD_Report_2017.pdf.

    I urge the Administration to return to the bipartisan 
consensus and accelerate the progress that PEPFAR and the 
Global Fund have allowed by prioritizing the fight against HIV/
AIDS in the FY 2020 budget request.
The Expanded Global Gag Rule Hampers the Fight to End
        HIV/AIDS
    On January 23, 2017, President Donald Trump reinstated the 
Global Gag Rule. Previous iterations of this policy barred 
foreign nongovernmental organizations (NGOs) from receiving 
U.S. bilateral family planning funds if they used private, non-
U.S. funds to perform legal abortions, offer counseling 
regarding abortion services, or advocate for access to safe, 
legal abortion. This policy is unwise, but the Trump 
Administration has made it even worse, expanding it to all 
foreign NGOs that receive U.S. global health assistance, 
including PEPFAR implementers.
    The effects of the Global Gag Rule are antithetical to the 
goals of the PEPFAR program. For example, a Mozambican 
Association for Family Development clinic in Mozambique's Xai-
Xai district tested nearly 6,000 patients for HIV over a three-
month period between July and September of 2017.\2\ During the 
next three-month period, the Global Gag Rule forced the clinic 
to forego U.S. funding, and just 671 patients were tested for 
HIV--a drop of more than 88 percent.\3\
---------------------------------------------------------------------------
    \2\``Prescribing Chaos in Global Health: The Global Gag Rule from 
1984-2018.'' Center for Health and Gender Equity. June 2018. http://
www.genderhealth.org/files/uploads/change/
publications/Prescribing_Chaos_in_Global_Health_full_report.pdf.
    \3\See 2.
---------------------------------------------------------------------------
    I urge the Administration to immediately rescind the Global 
Gag Rule and ensure that those served by U.S. global health 
assistance can continue to receive comprehensive care from the 
providers they trust. If the Global Gag Rule remains in effect, 
health care providers will continue to dramatically scale back 
essential services, like HIV tests, or close their doors 
altogether.\4\ This will endanger 15 years of progress in the 
global effort to end HIV/AIDS, much of which has been achieved 
with U.S. support.
---------------------------------------------------------------------------
    \4\Anna, Cara. ``Trump's global gag rule goes far beyond abortion, 
groups say.'' AP. January 23, 2018. https://www.apnews.com/
868c8211b4f948d8b7f7ce58ab08a78b/Trump's-global-gag-rule-goes-far-
beyond-abortion,-groups-say.

                                   Eliot L. Engel.

                                  [all]